Farhad Aziz, MD
The Ohio State University
Department of Emergency Medicine
1-Minute Review Video
Take Home Points
- Small pneumothorax (<15-25%), large pneumothorax (>25%)
- Tension pneumothorax: Decreased breath sounds, hypotension, deviated trachea
- Observation for small pneumothorax, Chest-tube for large pneumothorax
- ALWAYS needle decompression for tension (even if in the ED)
- Chest tube: 5th intercostal space, midaxillary line
- Needle Decompression: 2nd intercostal space, mid-clavicular line
Typically Asked Questions
- How should the patient be treated?
- Is this a tension pneumothorax? If so, what is the next step in management?
- Where should the chest tube or needle be placed?
A pneumothorax is when air enters the space between the visceral and parietal pleura. They can by primary (without an underlying lung condition) or secondary (with underlying lung disease). Risk factors for primary pneumothoraces include smoking, male gender, mitral valve prolapse, connective tissue disorders and large changes in pressures. Primary pneumothoraces have a high recurrence rate. Causes of secondary lung disease range from infection, connective tissue disease, interstitial disease, airway disease and cancer.
The most common symptoms associated with spontaneous pneumothorax is sudden onset dyspnea and chest pain. Patients also present with sinus tachycardia frequently. Other symptoms may include a cough and/or exertional dyspnea. However, these are uncommon complaints. It is important to differentiate the patient presenting with a spontaneous pneumothorax and one presenting with a tension pneumothorax.
Imaging modalities are the best way to confirm or exclude the diagnosis of pneumothorax. A chest x-ray is commonly the first modality to be used in making the diagnosis. Findings include a deep sulcus sign and lack of lung markings extending to the edge of the chest cavity. When compared to CT scan, chest x-rays are much less sensitive but still have great specificity. Chest CTs are much more sensitive and specific. A Chest CT should be obtained if a chest x-ray is negative but a pneumothorax is still suspected. Lung ultrasound is also a reasonable modality to determine whether a patient has a pneumothorax. Its sensitivity and specificity are much better than chest x-rays. A pneumothorax is diagnosed on ultrasound when there is an absence of lung sliding.
Treatment options include observation (conservative), needle aspiration or tube thoracostomy. The typical reabsorption rate is 1.25% per day. Administration of oxygen increases that rate. If the patient is stable is in no acute distress and has a small (<15%-25%) pneumothorax he/she is amenable to observation. All patients who are being observed should have serial chest x-rays done to ensure the pneumothorax is not expanding.
Needle aspiration can be used to reduce a moderately sized pneumothorax to a small pneumothorax. These patients can then be observed and managed conservatively.
Tube thoracostomy is the gold standard and is used for patients with a worsening pneumothorax, tension pneumothorax, a large (>25%) pneumothorax, unstable patients and patients who need positive pressure ventilation. Chest tubes are placed in the 5th intercostal space along the mid-axillary line. For simple pneumothoraces, the chest tube should be angled towards the apex of the affected lung.
Beyond the Boards
- FOAMcast: Pneumothorax
- REBEL EM: US for the Diagnosis of Pneumothorax
- PulmCC: Pneumothorax in the ICU
- EM Cases: Small bore chest tubes and outpatient management of pneumothoraces
- Nicks BA, Manthey D. Pneumothorax. In: Tintinalli JE, Stapczynski J, Ma O, Yealy DM, Meckler GD, Cline DM. eds. Tintinalli’s Emergency Medicine: A Comprehensive Study Guide, 8e New York, NY: McGraw-Hill; 2016.
- Rivers CS, Weber DE. Preparing for the Written Board Exam in Emergency Medicine. Vol 1. Milford, OH: Emergency Medicine Educational Enterprises; 2000.